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Spiral Tenodesis for Metacarpophalangeal Instability with Trapeziometacarpal Arthroplasty
Mark Henry, MD
Hand and Wrist Center of Houston, Houston, TX

Introduction: In more advanced stages of trapeziometacarpal arthritis, the thumb metacarpal may develop an adduction contracture, leading to secondary hyperextension instability of the metacarpophalangeal joint. Following trapeziometacarpal arthroplasty, uncorrected metacarpophalangeal hyperextension (greater than 50 degrees) may contribute to ongoing Z-collapse deformity, weakness of pinch and grip, and patient perception of diminished function. Fusion eliminates all metacarpophalangeal motion and may reduce interphalangeal motion. Local capsulodesis techniques using a volar incision can produce excessive local scar tissue around the digital nerves (paresthesias and hypersensitivity) and the flexor pollicis longus (reduced metacarpophalangeal and interphalangeal motion) as well as an initial rigid end-point that ultimately fails over time.

Materials & Methods: We prospectively analyzed a consecutive case series of 55 trapeziometacarpal arthroplasty patients (mean age 60, 7 males) that received simultaneous spiral tenodesis for thumb metacarpophalangeal hyperextension of at least 50 degrees. Through a 2 cm incision at the dorsal-ulnar metacarpophalangeal joint, the extensor pollicis brevis (detached proximally) was dissected distal to the axis of metacarpophalangeal motion, routed deep to the extensor pollicis longus, volar to the adductor aponeurosis, deep to the neurovascular bundles, and external to the flexor sheath in a spiral path to reach the radial base of the thumb metacarpal where it was anchored to the joint capsule and the accessory abductor pollicis longus. Before tensioning and anchoring the tenodesis, the metacarpophalangeal joint was pinned in 20 degrees of flexion with a 1.4 mm Kirschner wire, removed at 4 weeks post-operatively. Pre-operative / post-operative (mean 24 weeks) objective measurements and DASH scores were compared using paired t-tests with p < 0.05.

Results: Mean pre-operative / post-operative measurements were: metacarpophalangeal hyperextension 62.0 / -1.7 degrees; metacarpophalangeal flexion 52.1 / 50.1 degrees; interphalangeal arc of motion 66.4 / 65.5 degrees; key pinch 3.6 / 5.4 kg; grip strength 14.1 / 20.1 kg; DASH score 56.6 / 8.4. Differences were statistically significant for: metacarpophalangeal hyperextension, key pinch, grip strength, and DASH score. Differences were not significant for metacarpophalangeal flexion or interphalangeal arc of motion. No patient demonstrated paresthesias or hypersensitivity of the digital nerves. All patients achieved stability at the metacarpophalangeal joint. One Kirshner wire was removed earlier than planned after migration and penetration through the skin.

Conclusion: Performed in conjunction with trapeziometacarpal arthroplasty, spiral tenodesis effectively stabilizes the metacarpophalangeal joint without compromising metacarpophalangeal flexion, interphalangeal motion, or the digital nerves. Post-operatively, patients demonstrate significant improvements in key pinch, grip strength, and DASH scores.

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